Are there any injuries, medical conditions, allergies, special medications, or other issues that may affect your (or your minor’s) participation in this event? Please indicate in the space below. This information is confidential and will be shared only with program leaders or medical care providers.

By our signatures below, we acknowledge that we are aware of, appreciate the character of, and voluntarily assume the risks involved in participating in a Wilderness First Responder course, as detailed on the National Outdoor Leadership School, Wilderness Medicine Institute’s Student Agreement Form.

By our signatures below, on behalf of ourselves, our heirs, next of kin, successors in interest, assigns, personal representatives, and agents, we hereby:

Waive any claim or cause of action against and release from liability the State of South Dakota, its officers, employees, and agents for any liability for injuries to person or property resulting from participation in the activity listed above;

Agree to indemnify and hold harmless the State of South Dakota, its officers, employees, and agents for any claims, causes of action, or liability to any other person arising from participation in the activity listed above;

Consent to receive any medical treatment deemed advisable during participation in the activity listed above; and

Acknowledge that we are signing below as a minor child and as the parent or legal guardian of the minor child named below.

Give consent for BHSU to take photographs of me or my minor in connection with the above identified program, and agree that BHSU may use such images with or without a name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

If, for whatever reason, you do NOT want BHSU to use a photograph for the above stated purposes, but agree to the rest of the form herein, initial here:

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY AGREEMENT, PHOTO RELEASE AND CONSENT TO MEDICAL TREATMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

Participant's Electronic Signature

Date

If a minor, Guardian’s Electronic Signature

Date

If different, please provide Guardian's Address (street, city, state)

CONTACT INFORMATION:

Black Hills State University
College of Education
1200 University St. Unit 9401
Spearfish, SD 57799-9401
605.642.6027Christine.McCart@bhsu.edu